Foregut pathology

Question 1

List symptoms of upper GI disease

Answer 1

Chest pain
  Abdominal Pain
  Bleeding
  Nausea/Vomiting
  Dysphagia
  Anorexia
  Early Satiety
  Bloating

Question 2

On gross examination of the esophagus and the GEJ, squamous epithelium appears ____ and glandular epithelium appears _____ in color

Answer 2

squamous: white
glandular: tan or pink

Question 3

A “bag of worms” appearance on gross examination of the esophagus suggests

Answer 3

esophageal varices

dilated veins below the mucosal surface

Question 4

Histologic findings below suggest what diagnosis?
basal cell hyperplasia, intercellular edema, vascular congestion, extension of papillae toward the surface, inflammatory cell infiltrate (lymphocytes and eosinophils)

Answer 4

reflux esophagitis

Question 5

List complications of reflux esophagitis

Answer 5

erosion and ulceration
squamous papilloma
strictures
Barrett’s esophagus

Question 6

In ____, children usually have an identifiable allergic cause but adults do not

Answer 6

eosinophilic esophagitis

Question 7

Histologic findings below suggest what diagnosis?

Prominent intraepithelial eosinophils, eosinophilic microabscesses, intercellular edema, lamina propria fibrosis

Answer 7

eosinophilic esophagitis

Question 8

In order to diagnose candida esophagitis, you must see _______ of fungal elements

Answer 8

invasion

candida may be part of normal microflora, so surface fungal elements are not diagnostic

Question 9

_____ esophagitis is usually an opportunistic infection in immunosuppressed people but can also be seen in immunocompetent children

Answer 9

herpes

Question 10

______ usually presents with

• Ulcer with necrotic debris and exudate with neutrophil
• Viral inclusions are present in multinucleated squamous cells at margin of ulcer

Answer 10

herpes esophagitis

Question 11

_______ usually presents with:

• Virus present in enlarged endothelium and stromal cells at ulcer base
• Basophilic cytoplasm often has coarse intracytoplasmic granules
• Prominent intranuclear basophilic inclusions surrounded by clear halo (“Owl’s Eye”)

Answer 11

CMV esophagitis

Question 12

Differentiate herpes esophagitis from CMV esophagitis

Answer 12

herpes- present in squamous epithelium at surface of ulcer

CMV- present in endothelial cells deeper at the ulcer base

Question 13

Patients with Barrett’s esophagus are at increased risk of esophageal ________

Answer 13

adenocarcinoma

Question 14

Differentiate low grade from high grade dysplasia in the context of Barrett’s esophagus

Answer 14

low grade: nuclei are basally oriented
high grade: nuclei are apically oriented, my have more abnormal shape

both grades show mucus depletion and prominent cytoplasmic basophilia

Question 15

________ is typically is an exophytic mass with gastric rugae present below and pale squamous epithelium above, present in the distal esophagus

Answer 15

Adenocarcinoma of the esophagus

Question 16

______ is typically an exophytic, excavated, or infiltrative mass in the middle of the esophagus

Answer 16

squamous cell carcinoma of the esophagus

Question 17

What is the precursor lesion for squamous cell carcinoma of the esophagus?

Answer 17

squamous dysplasia

• loss of normal maturation
• mitosis present above the basal layer

Question 18

List cause of acute and chronic gastritis

Answer 18

acute gastritis

• drugs: EtOH, NSAIDs, steroids
• bile acids, uremia, shock, stress
• acute infection

chronic gastritis

• H pylori infection
• autoimmune gastritis
• reactive gastropathy

Question 19

How is H pylori diagnosed?

Answer 19

Histologic examination with or without special staining
Urease test using biopsy material
Urea breath test
Serologic test for antibodies to H. pylori
Molecular methods (PCR, ribotyping)

Question 20

What are complications of H pylori gastritis?

Answer 20

Peptic ulcer
Gastric adenocarcinoma
MALToma

Question 21

Antibodies in autoimmune gastritis are typically against:

Answer 21

parietal cells or intrinsic factor

anti-parietal cell antibodies are to the K/H APTase proton pump

Question 22

Loss of parietal cells in autoimmune gastritis leads to:

Answer 22

• hypochlorhydria
• loss of intrinsic factor (B12 malabsorption, pernicious anemia)
• low acid stimulates gastrin release lading to hyperplasia of antral G cells

Question 23

Gastric carcinoma is most frequently in the ______ area and along the _____

Answer 23

pyloric area and lesser curvature

Question 24

The ____ type of gastric adenocarcinoma presents with a bulky exophytic mass

Answer 24

intestinal

Question 25

The _____ type of gastric adenocarcinoma presents with infiltrative thickening of the stomach wall leading to the “leather bottle” appearance

Answer 25

diffuse

Question 26

Signet ring cells are associated with ______ gastric adenocarcinoma

Answer 26

diffuse

Question 27

Positive staining for CD20 (B lymphocytes) suggests _____

Answer 27

MALToma

Question 28

What is Plummer- Vinson syndrome?

Answer 28

Dysphagia due to esophageal webs, glossitis (inflammation of tongue), iron deficiency anemia; patients are at increased risk of squamous cell carcinoma of cervical esophagus

Question 29

Describe the microscopic findings of reflux esophagitis

Answer 29

Acute inflammatory cells in epithelial layer (eosinophils, neutrophils, excess T cells)
Basal cell hyperplasia and elongation of lamina propria papillae into upper 1/3 of epithelium
Ballooned squamous cells

Question 30

Describe the gross appearance of eosinophilic esophagitis

Answer 30

 White plaques
 Stipple-like exudates
 Linear fissures
 Ringed esophagus
 Strictures
 Impacted food

Question 31

Describe the microscopic appearance of eosinophilic esophagitis

Answer 31

 Prominent intraepithelial eosinophils 
 Microabscesses
 Basal cell hyperplasia
 Intercellular edema
 Lamina propria fibrosis

Question 32

What two criteria MUST be present to diagnose Barrett’s esophagus?

Answer 32

a) Must see abnormal epithelium at endoscopy ABOVE the GEJ

b) Histologic evidence of columnar epithelium with goblet cells on biopsy

Question 33

Describe the gross appearance of a peptic ulcer

Answer 33

 Peptic ulcers occur in the first part of the duodenum and in the gastric pylorus/antrum
 Classic peptic ulcer is a round to oval, sharply punched-out defect in the mucosa

Question 34

Differentiate the microscopic appearance of acute vs chronic ulcers

Answer 34

• Acute ulcer: Acute necrosis of surface epithelium. Underlying this is a zone of granulation tissue which consists of budding
  young capillaries and proliferating fibroblasts inflammatory cells. Below this is a zone of collagen deposition with healing which takes place
  from below upwards
• Chronic ulcer: granulation tissue is replaced by scar tissue